BRS Emergency Medicine - L. Stead (Lippincott, 2000)

13. Psychiatric Emergencies

I. Overview

A.  The American Psychiatric Association defines a psychiatric emergency as a situation that includes an acute disturbance of thought, behavior, mood, or social relationship which requires immediate intervention as defined by the client or family or social unit.

B.   From 2%–10% of all patients presenting to the emergency department (ED) have an acute psychiatric disturbance in addition to their ostensible presenting complaint.

C.  Most presentations occur at night. Up to 65% of patients presenting to the ED after midnight and before 8:00 A.M. have current or past psychiatric illness.

D.  The following presentations of life-threatening psychiatric conditions must be prioritized for identification and management:

§  Agitated, menacing, self-destructive, and out-of-control behavior

§  Serious and chronic self-neglect

§  Serious medical problems either coexisting with or causing psychiatric symptoms

§  Organic causes of acute presentations must be ruled out. See Chapter 6 I for causes and management of altered mental status.

E.   Criteria for involuntary commitment

1.   Danger to self

2.   Danger to others

3.   Danger to health

F.   Elements of emergency psychiatric care

0.   Establishment of rapport

§  Response to client and family needs

§  Expression of empathy

1.   Determination of physiologic status

§  Medical history and vital signs are obtained.

§  Necessary parts of physical examination are performed.

§  Results of diagnostic tests are obtained and reviewed.

2.   Physical and chemical restraints are used if necessary to provide safety to patient and others.

3.   Psychiatric status is obtained:

§  Precipitating events are identified.

§  Past personal, family, and psychiatric histories are obtained.

§  Mental status examination is performed.

§  Data are collected from patient's family and current therapist.

§  Provisional diagnosis is formulated.

4.   Proper disposition must be determined.

§  Inpatient or outpatient treatment, as appropriate, is arranged.

II. Approach to the Violent Patient

A. Factors predisposing to violence in the ED include:

§  high-stress illnesses

§  long waiting times

§  uncomfortable waiting environment (uncomfortable seats, no distraction, poor staff-to-family communication)

§  high-tension environment of ED

§  perceived ready availability of drugs and hostages

§  nonselective 24-hour open door policy with poor or absent security

§  increased use of drugs and alcohol in population of ED frequenters

B. Causes of violence in patients include:

§  acute organic brain syndrome (meningitis, encephalitis, brain abscess, or tumor)

§  intoxication

§  male gender

§  drug or alcohol withdrawal

§  acute psychosis or schizophrenia

§  paranoid personality

§  borderline personality

§  antisocial personality

§  depression with homicidal ideation

§  temporal lobe epilepsy

C. Clinical features

1.   Historical clues to identifying the potentially violent patient (the 7 A's):

§  Absent roots: patient's childhood is marked by divorce, parental deaths, frequent moves, job changes, child abuse.

§  Authority problems: patient has trouble taking orders from parents, teachers, and supervisors; gives nurses a hard time while they get vital signs.

§  Arrest record

§  Assaults: patient has multiple scars from chest tubes and exploratory laparotomies secondary to stab wounds. Patient states he is a fighter, is confrontational.

§  Another's death: patient has been involved in another's death, either “accidental” or intentional.

§  Alcohol or amphetamine abuse: patients are less inhibited.

§  Access: patient has ability to obtain weapons.

2.   Symptoms and physical examination findings may include:

§  tense posture

§  clenched fists

§  loud, threatening, insistent speech

§  psychomotor agitation

§  jumpiness

D. Diagnostic tests

§  Patient should be evaluated for the presenting complaint as well as for organic causes for the violent behavior. See Chapter 6 I for work-up of altered mental status.

1.   Complete blood count (CBC) to look for infection

2.   Chemistry panel to look for electrolyte abnormalities

3.   Toxicology screen to look for substance abuse

4.   Thyroid function tests (TFTs) to look for hyperthyroidism

5.   Head computed tomographic (CT) scan to look for intracranial pathology

6.   Lumbar puncture to look for brain infection and, when head CT is negative, for bleed

E. Treatment

1.   Stance: Face the patient and stand on patient's non-dominant side. People will strike with the dominant hand and kick with the dominant leg. The following guidelines help to determine which is the non-dominant side:

§  9 out of 10 people are right-handed

§  People usually wear their watches on their non-dominant or “weak” side.

§  The belt buckle usually points to the patient's “weak” side.

2.   Distance: ED personnel should stand 1½ leg-lengths from the patient, out of kicking range.

3.   Arms should hang at the side. Folded arms handicap a defensive attempt, and usually convey a hostile, domineering, authoritative stance.

4.   Limits must be established. The team is brought to the patient (force in numbers) and he or she is told that it is necessary to regain control.

5.   Eye contact must be avoided. Direct eye contact may put the patient on the defensive. The best place to gaze is at the upper chest, at the level of the first button of the collar or 9 inches below the chin.

6.   The exit must not be blocked, and the patient must not be positioned between two walls (in a corner).

7.   Staff should try to distract the patient. They may offer something to eat or drink.

8.   The patient should be given a chance to save face. Options should be offered, if possible, e.g., “Would you prefer the medication orally or by injection?”

9.   The patient should be offered chemical restraint (medical intervention): haloperidol 10 mg + lorazepam 4 mg intramuscularly (IM) or intravenously (IV).

10. If none of these strategies work, mechanical restraint is necessary. The team should establish a strategy, with one person assigned to each limb, one to the head, and a 6th person to put the restraints on.

F. Disposition

1.   Patients are admitted to the psychiatric floor if psychotic features (e.g., hallucinations, delusions) are present.

2.   If no psychotic features or suicidal or homicidal ideation are present and the patient calms down following treatment, he or she may be discharged home with outpatient psychiatric follow-up.

3.   If the work-up yields any medical cause for delirium, the patient is admitted to the appropriate service for further management.

4.   It is important to document that the patient has been properly handled.

III. Panic Attacks

A. Overview

§  Panic attacks are a form of anxiety limited to discrete episodes that are associated with an impending sense of doom.

§  Panic attacks may occur unexpectedly, or may be associated with specific situations.

B. Clinical presentation

§  Symptoms and physical examination findings may include:

1.   Motor tension

§  Trembling, twitching, or feeling shaky

§  Muscle tension, aches, or soreness

§  Restlessness

§  Easy fatigability

2.   Autonomic hyperactivity

§  Shortness of breath

§  Palpitations

§  Sweating, or cold clammy hands

§  Dry mouth

§  Dizziness or lightheadedness

§  Nausea, diarrhea, or other abdominal distress

§  Flushes (hot flashes) or chills

§  Frequent urination

§  Trouble swallowing or “lump in throat”

3.   Vigilance and scanning

§  Feeling keyed up or on edge

§  Exaggerated startle response

§  Difficulty concentrating or “mind going blank” because of anxiety

§  Trouble falling or staying asleep

§  Irritability

C. Diagnostic tests

§  No special diagnostic tests are necessary.

§  Laboratory tests that may be appropriate to exclude an organic cause of anxiety include:

1.   TFTs to look for hyperthyroidism

2.   Toxicology screen to look for amphetamines and sympathomimetics

3.   Electrocardiogram (ECG) to look for atrial fibrillation

D. Treatment

1.   Reassurance

2.   Encouragement to maintain control

3.   Breathing exercises to control psychogenic hyperventilation

4.   Benzodiazepines: the drug of choice in treating patients with anxiety. See Table 13-1 for specific drugs and dosages.

E. Disposition

1.   Most patients with panic attacks can be successfully evaluated and treated in the ED.

2.   Patients for whom an underlying medical disorder cannot be ruled out must be referred for further evaluation and therapy. If the suspected medical disorder is potentially life-threatening (e.g., unstable angina), the patient should be admitted to the hospital until it can be sorted out.

3.   Patients with panic disorder and suicidal or homicidal ideation or with major depression require urgent psychiatric consultation in the ED and admission to the psychiatry service.

4.   If the phobic stimulus is known, patients are instructed to avoid it.

Table 13-1. Benzodiazepines

Drug

Dosage

Half-life (hr)

Alprazolam

PO: 0.75–4 mg/24 h q 8 h

11–15

Chlordiazepoxide

PO: 15–100 mg/24 h in divided doses
IM: not recommended

6–30

Clorazepate

PO: 7.5–60 mg/24 h in 1–4 divided doses

30–100

Diazepam

PO: 6–40 mg/24 h in 1–4 divided doses
IV: 2.5–20 mg slowly
IM: not recommended

20–50

Flurazepam

PO: 15–30 mg qhs

50–100

Halazepam

PO: 20–40 mg q 6–8 h

Lorazepam

PO: 1–10 mg/24 h in 2–3 divided doses
IV/IM: 0.05 mg/kg to 4 mg maximum

10–20

Midazolam

IV: 0.035–0.1 mg/kg prn
IM 0.08 mg/kg

1–12

Oxazepam

PO: 30–120 mg/24 h in 3–4 divided doses

5–10

Prazepam

PO: 20–60 mg/24 h in divided doses or qhs

36–70

Temazepam

PO: 15–30 mg qhs

10

IM = intramuscularly; IV = intravenously; PO = orally; prn = as needed; q = every; qhs = at bedtime

IV. Affective Disorders

A. Depression

§  Depression may be connected with a history of a major life change such as the death of a spouse, retirement, or medical illness.

§  In younger people, depression may be seen in the context of a history of substance abuse, relationship problems, or job loss.

1.   Clinical presentation

a.   Symptoms may include:

§  loss of pleasure in daily activities (anhedonia)

§  early morning awakening

§  insomnia

§  depressed mood (50% of patients with depression report this)

§  sense of worthlessness

§  many somatic complaints and chronic pain, especially in the elderly

§  fatigue

b.   Physical examination findings may include:

§  stooped posture

§  slow speech

§  depressed facies

§  dry mouth

§  constipation

§  impaired memory and concentration on mini-mental status exam

2.   Diagnostic tests

§  No specific diagnostic tests are necessary for depression. However, medical causes for symptoms must be excluded before this diagnosis is made, because they can exist concurrently.

b.   CBC to look for infection

c.   Peripheral smear to look for neoplasia

d.   Chemistry panel to look for electrolyte abnormalities

e.   Serum toxicology screen to look for substance abuse

f.    Serum medication levels to look for toxicity (may not be intentional)

g.   Head CT scan to look for recent CVA

h.   TFTs to look for hypothyroidism

i.    Serology for Epstein-Barr virus

3.   Treatment

 .    Antidepressants: Patient may be put on a selective serotonin reuptake inhibitor (SSRI) such as fluoxetine 20–60 mg/day. (SSRIs have the least potential for serious toxic effects from abuse.)

a.   Therapy (outpatient)

4.   Disposition

 .    Most patients can be discharged home with outpatient psychiatric follow-up.

a.   Patients who have active suicidal or homicidal ideation should be admitted to the psychiatry service.

B. Mania

§  is a mood disorder that affects men and women equally.

§  begins in the early 20s.

§  has a familial predisposition: patients usually have a family history of affective disorders.

§  confers an increased risk for substance abuse.

§  often exists as part of bipolar disorder, an illness characterized by alternating periods of mania and depression.

1.   Clinical presentation

a.   Symptoms may include:

§  euphoria

§  elevated mood

§  sense of increased or endless energy

§  labile mood

§  easy frustration

§  demanding, egocentric behavior (grandiosity)

§  insomnia

§  poor judgment

§  paranoia, delusions, and hallucinations

b.   Physical examination findings may include:

§  flight of ideas

§  pressured speech

§  psychomotor agitation

2.   Diagnostic tests

a.   No specific diagnostic tests are necessary for mania.

b.   The differential diagnosis includes substance abuse and schizophrenia.

c.   The following laboratory studies may be helpful:

§  Serum toxicology screen to look for substance abuse

§  TFTs to look for hyperthyroidism

§  Serum ceruloplasmin if Wilson's disease is suspected

§  Serum lithium level if the patient is on that drug

3.   Treatment

a.   Antipsychotics: haloperidol, 10–40 mg over the first 24 hours

b.   Benzodiazepines as needed (see Table 13-1)

c.   Consultation with psychiatry department

d.   Electroconvulsive therapy (ECT) in consultation with the psychiatry department, if none of the above control acute episode

e.   Lithium: begun at 300 mg orally every 6 to 8 hours (maximum dose is 2.4 g/day) to maintain remission (maintenance dose is 900–1800 mg/day; steady state is reached in 5 days); or carbamazepine, begun at 200 mg orally twice a day.

4.   Disposition

a.   Patients who are acutely manic should be hospitalized, because they may be at risk of hurting themselves or getting into trouble with the law as a result of poor judgment.

b.   Patients who are hypomanic may be discharged home with outpatient psychiatric follow-up.

V. Psychosis

A. Overview

§  The psychotic patient has a grossly impaired sense of reality.

§  The most common psychosis is schizophrenia.

§  Any underlying medical condition (organic cause) must always be ruled out.

B. Clinical presentation

§  Symptoms and physical examination findings may include:

§  no clouding of consciousness

§  blunt, inappropriate, or labile affect

§  thought disturbances in patient with clear sensorium

§  short attention span

§  speech that contains neologisms, echolalia, clanging

§  presence of delusions

§  presence of hallucinations

§  unkempt appearance

C. Diagnostic tests

§  No specific diagnostic tests are necessary for schizophrenia.

§  As always, medical causes of symptoms must be excluded.

D. Treatment

1.   Control of any violent behavior (see section II).

2.   Sedation and chemical restraint:

§  Haloperidol 2–10 mg orally or IM every 1–8 hours

§  Droperidol 2.5–10 mg orally or IM every 3–4 hours

§  Benzodiazepines as needed (see Table 13-1)

3.   Minimal-stimulus environment

E. Disposition

§  Acutely psychotic patients should be admitted to the psychiatry service.

VI. Conversion Disorder

A. Overview

§  In conversion disorder, the patient has loss of function of a part of the nervous system, but no underlying organic cause can be identified.

§  Primary gain may be involved: disability may be symbolic for other (non-physical) pain that the patient has suffered and is trying to repress.

§  Secondary gain may be involved (e.g., need to play sick role, wish to obtain worker's compensation).

§  The relationship to the cause of the disorder may be obvious to the examiner, but the patient lacks insight, does not understand, and does not voluntarily produce symptoms.

§  Conversion disorder often occurs abruptly, following a stressor.

B. Clinical presentation

1.   Symptoms may include:

§  paralysis

§  seizures

§  urinary retention

§  blindness

§  deafness

§  unconsciousness

§  paresthesias

2.   Physical examination often is normal, although patients may develop contractures from presumed paralysis.

C. Diagnostic tests

§  No special diagnostic tests are necessary, but diagnosis can only be made after organic causes for the patient's symptoms have been ruled out.

D. Treatment

§  consists of reassurance.

E. Disposition

§  Patients can be discharged home with outpatient follow-up.

VII. Eating Disorders

A. Anorexia nervosa

§  Anorexia nervosa begins in adolescence and is seen 10 times more frequently in women.

§  It involves a distorted body image (i.e., feeling fat when this clearly is not true).

§  Patients often have poor family dynamics and a history of poor self-image, vigorous exercise, and laxative and diuretic abuse.

1.   Clinical presentation

a.   Symptoms and physical examination findings may include:

§  weight loss (patients are underweight)

§  no appetite loss

§  amenorrhea

§  edema

§  bradycardia

§  hypothermia

§  chronic pain

§  fatigue

2.   Diagnostic tests

§  No special diagnostic tests are necessary unless the diagnosis is unclear.

§  The differential diagnosis includes depression and schizophrenia.

§  Helpful laboratory tests may include:

d.   CBC to look for anemia

e.   Chemistry panel to look for metabolic acidosis

f.    Urinalysis to look for ketones

g.   ECG to look for rhythm and rate disturbances

3.   Treatment

 .    Individual therapy

a.   Family therapy

b.   For severe cases: IV fluids and hyperalimentation

4.   Disposition

 .    Patients who are not in immediate danger of starvation may be discharged home with outpatient follow-up.

a.   Patients with severe anorexia nervosa should be hospitalized for IV hyperalimentation.

B. Bulimia nervosa

1.   Overview

§  Bulimia nervosa is a condition related to anorexia nervosa that involves binge eating followed by purging via vomiting, alternating with periods of self-starvation.

§  It is 10 to 20 times more common in women overall, but more common in men than anorexia alone.

2.   Clinical presentation

§  Symptoms and physical examination findings may include:

§  history of going to the bathroom immediately after meals (to vomit)

§  erosion of tooth enamel (secondary to the acid produced with vomiting)

§  normal weight

3.   Diagnostic tests

§  No special diagnostic tests are necessary unless the diagnosis is unclear.

§  The differential diagnosis includes depression, schizophrenia, and borderline personality disorder.

4.   Treatment

a.   Antidepressants: may start an SSRI, such as fluoxetine 20–60 mg/day

b.   Cognitive therapy

5.   Disposition

§  Most patients can be discharged home with outpatient follow-up.

VIII. Domestic Violence

§  Domestic violence is defined by the American College of Emergency Physicians (ACEP) as “part of a pattern of coercive behaviors that an individual uses to establish and maintain power and control over another with whom he/she has had an intimate, romantic, or spousal relationship” (ACEP Policy Statement on Domestic Violence [No. 4163], Feb. 1999).

A. Clinical features

§  Symptoms and physical examination findings of domestic violence are similar to those found in child maltreatment (see Chapter 20 IX) and, as in the case of suspected child maltreatment, are required to be reported by the physician. These may include:

§  multiple injuries in different stages of healing

§  injuries that are inconsistent with the reported mechanism of action

§  maxillofacial trauma, especially periorbital ecchymosis

§  bruises and fractures of the forearms

§  chronic pain: pain in the pelvis, abdomen, and chest, and headaches

§  symptoms of depression or mania

§  term pregnancy without prenatal care, due to blocked access

§  exacerbation of chronic illnesses due to blocked access to medications

B. Diagnostic tests

§  No specific diagnostic tests are necessary. Underlying illnesses should be looked for, and injuries should be documented. Radiographs may be helpful in this regard.

C. Treatment

1.   A safe environment is provided for the patient.

2.   Psychiatry consult is arranged.

3.   Social work consult is arranged.

D. Disposition

1.   Patients whose acute injuries have been treated and who have a safe place to go (e.g., shelter, friend's home) may be discharged with outpatient follow-up.

2.   Patients who do not have a safe place to go should be hospitalized until social services can be arranged.

IX. Elder Abuse

§  As with child abuse and domestic violence, suspicion of elder abuse is required to be reported by the physician.

A. Symptoms and physical examination findings may include:

§  physical neglect

§  unkempt appearance

§  malnourishment

§  lack of adequate clothing (especially in winter)

§  untreated medical conditions

§  depressed facies

§  sense of shame or guilt

B. Diagnostic tests

§  No specific tests are necessary to diagnose elder abuse. However, all patients should receive baseline testing to exclude any underlying untreated medical conditions.

C. Treatment

1.   Treatment of any infections, injuries, or electrolyte abnormalities

2.   IV hydration

3.   Psychiatry consult

4.   Social work consult

D. Disposition

1.   Patients whose acute injuries have been treated and who have a safe place to go (e.g., shelter, friend's home) may be discharged with outpatient follow-up.

2.   Patients who do not have a safe place to go should be hospitalized until social services can be arranged.

X. Suicide

A. Clinical features

1.   Symptoms may include:

§  frequent ED visits secondary to noncompliance with essential medications

§  self-inflicted wounds

§  overdose of medications or drugs of abuse

§  heavy alcohol drinking in a patient with alcoholic liver disease

§  motor vehicle accidents with single vehicle and single victim (patient)

§  symptoms of depression (see section IV)

2.   Physical examination findings may include:

§  scars

§  wounds

§  occult weapons

B. Risk factors

§  Caucasian race

§  Male gender

§  Age > 65 years

§  Age group 15–24 years, especially in males

§  History of psychiatric disorder

§  Ongoing substance abuse

§  History of prior suicide attempts

§  Terminal or chronic illness

§  History of personal abuse (inflicted by self or others)

§  Family history of suicide

§  Recent discharge from psychiatric hospital

§  2- to 3-week “remission” period after starting antidepressant therapy

§  Single, divorced, or separated status

§  Living alone

§  Recent loss of job or death of family member

§  Access to firearms

§  Feelings of worthlessness and excessive guilt

C. Diagnostic tests

§  No specific diagnostic tests are necessary. Acute poisoning and trauma should be evaluated. Underlying medical diseases should be sought.

D. Treatment

1.   Benzodiazepines to manage anxiety, as needed (see Table 13-1)

2.   Reassurance

E. Disposition

§  Patients who are actively suicidal or homicidal should be hospitalized for further management. See section I for criteria for involuntary confinement.

Review Test

1. A 23-year-old woman presents to the ED after slashing her wrists with a razor blade following an argument with her boyfriend. She has a past medical history for asthma, but takes no medications. She has presented to the ED previously for similar self-abuse and states she often has “relationship problems.” What is the single most important question to ask this patient?

(A) Do you want to hurt or kill yourself or any other person?

(B) Do you use drugs or alcohol?

(C) Is there any possibility you might be pregnant?

(D) Is your boyfriend physically or sexually abusing you?

(E) Were you abused physically or sexually as a child?

1-A. Although all the questions suggested probably will be helpful in evaluating this patient, the most urgent question to ask is about suicidal or homicidal ideation, which is a psychiatric emergency. Patients who are suicidal or homicidal should be on a 1:1 hold (observed at all times), searched for weapons, restrained (for their own protection and the protection of others) if necessary, and admitted to the psychiatry service after medical clearance. Information regarding drug or alcohol use, possible pregnancy, and physical or sexual abuse, either current or in the past, can be obtained later.

Questions 2 and 3

A 41-year-old Wall Street executive is brought to the ED by his worried family. A few days ago, he came home proclaiming he had discovered the secret to happiness. The family states he has had boundless energy since then, finishing all the chores on his “life's to-do list” in a single evening. They became extremely worried when he quit his job yesterday and liquidated his hard-earned savings to buy a very expensive yacht.

2. Which of the following medications is likely to be most helpful to this patient?

(A) Phenytoin

(B) Droperidol

(C) Lorazepam

(D) Lithium

(E) Amitryptylline

2-D Lithium is the first-line drug for the treatment of mania. If lithium does not work, carbamazepine may be effective. Other anticonvulsants such as phenytoin are not effective. Lorazepam and droperidol will not help the mania, although they may produce a slight sedating effect. Amitryptylline and imipramine are tricyclic antidepressants that are used to treat many disorders, but not mania.

3. Which of the following is the second medication to use if the first drug is not effective in controlling this patient's symptoms?

(A) Lithium

(B) Droperidol

(C) Carbamazepine

(D) Lorazepam

(E) Iimipramine

3-C. Lithium is the first-line drug for the treatment of mania. If lithium does not work, carbamazepine may be effective. Other anticonvulsants such as phenytoin are not effective. Lorazepam and droperidol will not help the mania, although they may produce a slight sedating effect. Amitryptylline and imipramine are tricyclic antidepressants that are used to treat many disorders, but not mania.

4. Which of the following is the drug of choice in the treatment of panic disorder?

(A) Nortryptaline

(B) Haloperidol

(C) Lithium

(D) Alprazolam

(E) Fluoxetine

4-D. The drug of choice for simple panic disorder (without concurrent depression) is a benzodiazepine. Alprazolam is the only benzodiazepine listed in the answer choices. (Other benzodiazepines are listed in Table 13-1.) Nortryptylline is a tricyclic antidepressant. Haloperidol is an antipsychotic. Lithium is used to treat mania. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used to treat depression.

5. Which of the following is a risk factor for successful suicide?

(A) Substance abuse

(B) Being married

(C) Having a demanding job

(D) Female gender

(E) Lack of underlying medical illness

5-A. Substance abuse is a risk factor for suicide for more than one reason. First, substance abuse may have begun with a poor self-image and a need to fit in. Second, procurement of many drugs may put the abuser in dangerous places and situations. Finally, the addiction can create isolation, depression, and anxiety in the abuser. Single people and those who live alone are more prone to suicide than married people or those with a close circle of friends and family. Females are three times more likely to attempt suicide, but are only one third as likely to succeed at their attempts. The presence rather than the lack of a medical illness is more often associated with suicide. Finally, although having a demanding job may be stressful, unemployment is more often associated with suicide.

Directions: The response options for Items 6–9 are the same. Each item will state the number of options to choose. Choose exactly this number.

Questions 6–9

Match the symptoms that often are present with the illness.

A.  (A) Anorexia

B.   (B) Distorted body image

C.  (C) Anhedonia

D.  (D) Insomnia

E.   (E) Poor concentration

F.   (F) Endocrine abnormalities

G.  (G) Fatigue

H.  (H) Vomiting

I.    (I) Diarrhea

6. Depression (select 5 symptoms)

6-A, C, D, E, G. Depression may be marked by anorexia, anhedonia, insomnia, poor concentration, and fatigue.

7. Anorexia nervosa (select 5 symptoms)

7-A, B, E, F, G. Anorexia nervosa is marked by anorexia, distorted body image, poor concentration, endocrine abnormalities, and fatigue.

8. Bulimia (select 4 symptoms)

8-A, B, F, H. Bulimia nervosa is characterized by anorexia (patients go back and forth between binge eating and starving), distorted body image, endocrine abnormalities, and vomiting.

9. Anxiety (select 4 symptoms)

9-D, E, G, I. Anxiety is marked by insomnia, poor concentration, fatigue, and diarrhea.